Early infant diagnosis testing for HIV in a hard-to-reach fishing community in Uganda

Background Infants born to HIV-infected mothers are at a high risk of acquiring the infection. The World Health Organization recommends early diagnosis of HIV-exposed infants (HEIs) through deoxyribonucleic acid polymerase chain reaction (DNA PCR) and rapid HIV testing. Early detection of paediatric HIV is critical for access to antiretroviral therapy (ART) and child survival. However, there is limited evidence of the factors associated with receiving early infant diagnosis (EID) tests of the HIV testing protocol among HEIs in fishing communities in Uganda. This study established the factors associated with receiving EID tests of the HIV testing protocol among HEIs in a hard-to-reach fishing community in Uganda. Methods A cross-sectional study was conducted among HEIs in selected healthcare facilities in Buvuma islands, Buvuma district. We obtained secondary data from mother-infant pair files enrolled in the EID program using a data extraction tool. Data were analysed using STATA Version 14. A modified Poisson regression analysis was used to determine the factors associated with not receiving the 1st DNA PCR test among HEIs enrolled in care. Results None of the HEIs had received all the EID tests prescribed by the HIV testing protocol within the recommended time frame for the period of January 2014-December 2016. The proportion of infants that had received the 1st and 2nd DNA PCR, and rapid HIV tests was 39.5%, 6.1%, and 81.0% respectively. Being under the care of a single mother (PR = 1.11, 95% CI: 1.01–1.23, p = 0.023) and cessation of breastfeeding (PR = 0.90, 95% CI: 0.83–0.98, p = 0.025) were significantly associated with not receiving the 1st DNA PCR. Conclusion Our study revealed that none of the HEIs had received all the EID tests of the HIV diagnosis testing protocol. Receiving the 1st DNA PCR was positively associated with being an infant born to a single mother, and exclusive breastfeeding. Our findings highlight the need for the creation of an enabling environment for mothers and caregivers in order to increase the uptake of early diagnosis services for HEIs. Awareness-raising on the importance of EID should be scaled up in fishing communities. Demographic characteristics such as marital and breastfeeding status should be used as an entry point to increase the proportion of HEIs who receive EID tests.


Abstract:
Background Infants born to HIV-infected mothers are at a high risk of acquiring the infection. The World Health Organization (WHO) recommends early diagnosis of HIV-exposed infants (HEIs) through deoxyribonucleic acid polymerase chain reaction (DNA PCR) and rapid HIV testing. Early detection of paediatric HIV is critical for access to antiretroviral therapy treatment (ART) and child survival. There's, however, limited evidence of the adherence to early infant diagnosis (EID) of HIV testing protocol among HEIs in fishing communities in Uganda. This study assessed adherence to EID of HIV testing protocol among HIV-exposed infants in a hard-to-reach fishing community in Uganda. Methods We conducted a cross-sectional study employing quantitative data collection methods among HEIs in selected healthcare facilities in Buvuma islands, Buvuma district. We obtained secondary data from mother-infant pair files enrolled on the EID program using a data extraction tool. Data were analysed using STATA Version 14. Modified poisson regression analysis was used to determine the factors associated with nonadherence to the 1 st DNA PCR test among HIV-exposed infants enrolled into care.

Results
None of the HIV-exposed infants had done all the EID tests prescribed by the HIV testing protocol within the recommended time frame for the period of January 2014-December 2016. Adherence to the 1 st and 2 nd DNA PCR, and rapid HIV tests was 39.5%, 6.1% and 81.0% respectively. Being under the care of single mothers (PR=1.11, 95% CI: 1.01-1.23, p=0.023) and cessation of breast feeding (PR=0.90, 95% CI: 0.83-0.98, p=0.025) were significantly associated with non-adherence to the 1 st DNA PCR. Conclusion None of the HIV-exposed infants adhered to all the EID tests of HIV testing protocol. Adherence to the 1st DNA PCR was positively associated with being a single mother and exclusive breast feeding. Therefore, single mothers and those who stop breastfeeding should be supported to ensure timely EID. Infants born to HIV-infected mothers are at a high risk of acquiring the infection. The World 28 Health Organization (WHO) recommends early diagnosis of HIV-exposed infants (HEIs) through 29 deoxyribonucleic acid polymerase chain reaction (DNA PCR) and rapid HIV testing. Early 30 detection of paediatric HIV is critical for access to antiretroviral therapy treatment (ART) and child 31 survival. There's, however, limited evidence of the adherence to early infant diagnosis (EID) of 32 HIV testing protocol among HEIs in fishing communities in Uganda. This study assessed 33 adherence to EID of HIV testing protocol among HIV-exposed infants in a hard-to-reach fishing 34 community in Uganda.

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We conducted a cross-sectional study employing quantitative data collection methods among HEIs 37 in selected healthcare facilities in Buvuma islands, Buvuma district. We obtained secondary data 38 from mother-infant pair files enrolled on the EID program using a data extraction tool. Data were 39 analysed using STATA Version 14. Modified poisson regression analysis was used to determine 40 the factors associated with non-adherence to the 1 st DNA PCR test among HIV-exposed infants 41 enrolled into care.

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None of the HIV-exposed infants had done all the EID tests prescribed by the HIV testing protocol None of the HIV-exposed infants adhered to all the EID tests of HIV testing protocol. Adherence 51 to the 1st DNA PCR was positively associated with being a single mother and exclusive breast 52 feeding. Therefore, single mothers and those who stop breastfeeding should be supported to ensure 53 timely EID. Despite significant scale-up of programs to prevent mother-to-child transmission (MTCT) of HIV, over 90% of new infections among infants and young children still occur during pregnancy, child birth, or through breastfeeding [2]. More than 150,000 children were newly infected with HIV while 100,000 died from AIDS-related causes in 2020 [1, 3]. The majority of these live-in resource-limited settings in sub-Saharan Africa, where up to 30% of untreated HIV-infected children die before their first birthday, and more than 50% die before they reach 2 years of age [4]. Owing to the risk of mortality before the age of 2 years among HIV-infected infants, the World Health Organization (WHO) recommends that national programmes should establish the capacity to provide early virological testing of HIV-exposed infants for HIV at six weeks or as soon as possible thereafter to guide clinical decision-making at the earliest possible stage. All infants with unknown or uncertain HIV exposure who are brought for healthcare at or around birth or at the first postnatal visit should get a 1 st polymerase chain reaction (PCR) test within 6-8 weeks or the earliest opportunity thereafter followed by a 2 nd PCR 6 weeks after cessation of breastfeeding. In addition, the Ugandan Ministry of Health (MoH) guidelines recommend a Dry Blood Spot (DBS) for confirmatory DNA PCR for all infants who test positive on the day they start ART; a DNA PCR test for all HEIs who develop signs and symptoms suggestive of HIV during follow-up, irrespective of breastfeeding status as well as a rapid HIV test at 18-24 months for all infants who test negative at 1 st or 2 nd PCR [7,8].
Early infant diagnosis provides an opportunity to offer optimal and timely treatment of HIVinfected children and informs decision-making on infant feeding which improves treatment outcomes [9,10]. Whereas EID is important in mitigating MTCT, its implementation has been challenging in resource-limited settings. For instance, more than two fifths (40%) of the infants living with HIV worldwide were left undiagnosed in 2020 [3,11]. Similarly, the HIV status was unknown for nearly two-thirds (60.6%) of the children aged 0-4 years living with HIV in Uganda Current evidence shows that fishing communities in Uganda have higher HIV incidence rates and prevalence compared to the general population [14]. The fact that the HIV prevalence and incidence rates are high implies that the number of HEIs is likely to be high. This therefore requires strengthening EID in the health facilities. There's, however, a dearth of evidence of the adherence to EID of HIV testing protocol and associated factors among HIV exposed infants in fishing communities in Uganda. Therefore, this study aimed at assessing the adherence to EID of HIV testing protocol among HIV exposed infants in a hard-to-reach fishing community in Buvuma district, Uganda. We used the Andersen and Newman's framework to examine the factors that either facilitated or impeded utilization of EID services. According to Andersen and Newman (15), there are three key elements in the model: predisposing factors (which include, demographic characteristics, social structural variables, and an individual's basic beliefs, attitudes, and knowledge pertaining to health services), enabling (resources available, whether individually or in a community), and need-for-care factors (illnesses, conditions, and health statuses requiring health services), which either facilitate or hinder the utilization of services by individuals.

Study design and area
A cross-sectional study employing quantitative data collection methods was conducted in Buvuma islands, Buvuma district, Uganda. Buvuma district is made up of 52 scattered islands in the northern shores of Lake Victoria in central region of Uganda. In 2014, Buvuma islands had a population of 89,890 people, of which 48,414 were males and 41,476 were females [16]. Fishing is the major economic activity in the area. Given that the population in Buvuma is a fishing community, it is considered to be at a high risk for transmission of HIV. Available data indicates that the HIV prevalence in Buvuma islands is as high as 11.5% , and is above the national private-not-for profit (PNFP). It has one Health centre IV, four Health centre IIIs and the rest being health centre IIs [18]. Early infant diagnosis services are offered in all the health facilities.

Study population and eligibility criteria
The study population were mother-infant pairs who enrolled on the EID program between January 2014 and December 2016 in the selected healthcare facilities. This period was chosen because infants were expected to have completed the 2-year EID cascade. Mother-infant pair files with missing data on key variables (e.g. age, sex of the infant, marital status, level of education) were excluded from the sample.

Sample size determination and sampling technique
The sample size was estimated using the Leslie Kish formula [19] = [ [( 2 * * ) + 2 ] [( 2 + 2 * * )/ ]] An estimated prevalence of 32% of HEIs who complete the EID testing cascade [20] was considered, the standard normal deviate at 95% confidence (1.96), and a 5% margin of error yielded a minimum sample size of 190 mother-infant pair files. Considering a missingness of files of 40% based on a study by Gloyd,Wagenaar (21).
The calculated sample size was 317. The distribution of mother-infant files per selected healthcare facility was based on sampling proportionate to size as is indicated in Table 1 below. Sampling procedure The health facilities were categorized depending on levels of health centre. The district has one health centre IV and three health centre IIIs. Purposively, the one health centre IV and all IIIs were selected since they are mandated to offer ART services including EID. Simple random sampling without replacement was used to select two health centre II's out of the five for geographical representation of the island. For health centre II's, their names were written on pieces of paper, folded and put in separate boxes depending on the level of care. The box was shaken such that they are mixed. A piece of paper was then picked at a time without replacement. At each level, two health facilities were selected the health facility name was written down.

Study variables and measurement
The

Data collection procedures and tools
A review of EID registers, mother-infant pair files, ART registers and DBS dispatch forms was done to determine adherence to EID testing protocol basing on the standard of MOH guidelines.
A data extraction tool was used to collect information on the health facility variables as well as infant and mother characteristics.

Data management and analysis
Data were field edited for consistence and omissions. Electronic data were transferred from In order to determine the factors associated with non-adherence to the 1 st DNA PCR among HEIs enrolled into care in Buvuma islands, Buvuma district, categorical variables were cross tabulated to identify the proportion of cases within a subgroup. Thereafter, bivariate analysis was conducted to determine the relationship between the independent and outcome variable. Unadjusted prevalence ratios, corresponding 95% confidence intervals and p-values were obtained using 'modified' Poisson regression. All independent variables associated with non-adherence to 1 st DNA PCR test at bivariate analysis with a p-value of less than 0.20 were considered for multivariable analysis. "Modified' Poisson regression analysis was used to obtain adjusted prevalence ratios given that the prevalence of non-adherence to the 1 st DNA PCR was common (greater than 10%) [22]. During model building, a forward stepwise strategy was used [23,24].
This involved a stepwise addition of independent variables into multivariable model. After adjusting for the individual independent variables, a p value of less than 0.05 was considered statistically significant.

Quality control and assurance
We recruited a total of 5 research assistants. In order to ensure quality control, all the research assistants received a two-day training on the study, research ethics, use of the data extraction tool, and were supervised during data collection and entry process. Pre-visiting the study area and pretesting of the study instruments was done to ensure the appropriateness of the questions for reliable and accurate information. The data abstraction tool was pre-tested from Busi Health Centre IV located at Busi Island, Wakiso district. This was deemed appropriate since it also serves as a hard to reach fishing community on Lake Victoria with characteristics similar to those of Buvuma islands. After the pre-test, appropriate adjustments on the tool were made before actual data collection.

Ethical approval and consent to participate
This study was reviewed and approved by the Makerere University School of Public Health Higher Degrees and Research Ethics Committee (MakSPH HDREC). Permission to conduct this study was also sought from Buvuma District Local government.

Flow chart for mother-infant file
A total of 435 files were screened, among these, 125 did not have information on the variables of interest (Figure 1).

Sample collection and communication of EID results to mothers and caretakers
Almost all (98.1%, 304/310) the mother-infant pair files indicated that the 1 st PCR sample was collected; 43.9% (132/298) indicated that the 2 nd PCR sample was done while only 46.4% (137/295) indicated that the rapid diagnostic test for the infant had been done (Table 3).

Average time taken to undergo EID tests and turnaround time
The average time taken by infants to undergo the 1 st PCR and 2 nd PCR tests was 14.5 (SD±16.8) and 61.0 (SD±29.1) respectively, while the average time taken to undergo the rapid diagnostic test was 84.1 (SD±23.4). The average time taken from testing to receiving results (turnaround time) for the 1 st and 2 nd PCR was 11.4 (SD±21.1) and 11.9 (SD±35.1) respectively (Table 4).   (Table 6).

Factors associated with non-adherence to 1 st DNA PCR test
The prevalence of non-adherence to the 1 st DNA PCR test was 11% higher among infants of single mothers compared to those whose mothers were married after adjusting for time of mother   [25,26].
Our study revealed that the prevalence of non-adherence to the 1 st DNA PCR test was higher among infants of single mothers compared to those whose mothers were married. This could be to the fact that single mothers have limited support for transport needs as well as food and reminders to go to the healthcare facility. These have been shown to affect the mothers' motivation towards taking their infants for EID services. This is in line with the findings of Bwana et al., (2016) who reported that lack of partner support hindered adherence of infants to EID. Our findings indicate a need to sensitize mothers, especially those who are single on the significance of EID. In addition, the study found that the prevalence of non-adherence to the 1st DNA PCR test was lower among infants of mothers who were no longer breast feeding compared to those of mothers practicing exclusive breast feeding. This could be attributed to the reduced bonding between the mother and the infant, and the fact that mother's assumption that their infants cannot contract the virus once not breast feeding.
Our study revealed that only 31.3% of infants of clients who had not disclosed their HIV status to their partners had adhered to the testing cascade compared to 40.6% of infants of clients who had disclosed their HIV status to their partners. This could be because disclosure of HIV status to partners is associated with spousal support in the form of money to facilitate transport to the healthcare facility, and reminders and accompaniment to the healthcare facility for the services.
Consequently, this could influence adherence to EID. Our findings concur with those reported in Uganda which showed that HIV status disclosure by women to partners was associated with increased spousal support and increased visits to healthcare facilities [27,28]. This indicates a need for encouraging disclosure of HIV status in order to enhance adherence to EID testing services.
Nearly half (44.7%) of the infants of clients who lived ≤5kilometers from the healthcare facility and only 36.8% of the infants of clients who lived >5kilometers from the healthcare facility had adhered to the 1 st PCR test. Longer distance from the healthcare facility implies that the mother would incur higher transportation costs, which could in turn impede adherence to EID testing services. Similarly, Samson,Mpembeni (29) in a study conducted to assess the uptake of EID at six weeks after cessation of breastfeeding among HIV-exposed children in Tanzania reported that the most common reasons for non-uptake of the test mentioned by respondents were long distance from home to the healthcare facility (22.9%, 95% CI: 20.3-25.4).

Strengths and limitations
This study may have been the first to examine the adherence to EID in a hard-to-reach fishing community. Therefore, it provides useful insights into utilisation of EID testing services in such settings. The study utilises a relatively large sample size which makes the findings generalizable in a similar setting. This study was, however, affected by missing data in the patient files.
Nonetheless, missingness of data had been catered for in the sample size calculation. Furthermore, findings from this study can only be applied to hard-to-reach fishing communities and may not be applicable to other hard-to-reach populations especially communities that are not mobile.